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<br />YES NO <br />Gl D RULE #32 - NON-COVERED BENEFITS OR INVALID <br /> CODES <br /> Whenever a procedure code that represents a non-covered <br /> benefit is billed it will deny. <br />[i] D RULE #33 - MULTIPLE DISALLOWED PROCEDURES <br /> Whenever a physician bills for procedures beyond the <br /> frequency for which the procedure could possibly be <br /> performed, it will deny, (ie. more than I hysterectomy). <br />I2J D RULE #34 - DUPLICATE PROCEDURES <br /> Whenever a physician bills the same procedure code more <br /> than once for the same patient on the same date of service (DOS) it <br /> will deny. <br />[i] D RULE #35 - MANDATORY OUTPATIENT <br /> PROCEDURES <br /> Whenever a physician bills for a procedure that is generally <br /> accepted as being done only in an ambulatory setting, however <br /> is done on an inpatient basis, it is flagged for investigation. <br />[II D RULE #36 - POTENTIAL COORDINATION OF <br /> BENEFITS <br /> Whenever a physician bills for a diagnosis that is <br /> representative of possible motor vehicle accident origin or <br /> workers' compensation, it is flagged for review. <br />[!] D RULE #37 - OFFICE VISIT UPCODING <br /> Whenever a physician bills for an extensive or comprehensive <br /> office visit that is in excess of the appropriate frequency for <br /> that diagnosis of the patient, it is flagged for review. <br />[!] D RULE #38 - INAPPROPRIATE CODES <br /> Whenever a procedure code that is not appropriate for the <br /> gender or age of the patient is billed, it will deny. <br />[II D RULE #39 - SENTINEL EVENTS <br /> Whenever a physician bills for a procedure or diagnosis that is <br /> representative of a possible quality of care issue, it is flagged <br /> for review. <br /> <br />5 <br /> <br />mL <br /> <br /> <br /> <br />GROUP Bt:NEFITS RISK POOL <br />